PERSON CENTERED THERAPY

Earnest Hemmingway, Carl Rogers and Abraham Maslow "A Person Centered Approach"

Discussion

Atomoxetine was approved as treatment for ADHD in people who cannot take psychostimulants on the basis of cost-effectiveness compared with placebo.1 The PBAC accepted that atomoxetine is significantly more effective than placebo for treating ADHD, and that there is a clinical need for atomoxetine, particularly among people who are unable to take dexamphetamine and methylphenidate.2 The manufacturer's submission to the PBAC did not request a listing for patients who fail to respond to, or become tolerant to, psychostimulants. The PBAC did not accept that atomoxetine has a superior toxicity profile to that of psychostimulants when it was unsuccessfully submitted for a first-line PBS listing in 2005. When drugs are required for managing ADHD, the psychostimulants methylphenidate and dexamphetamine are first line, combined with non-drug interventions according to individual needs. The noradrenaline reuptake inhibitor atomoxetine is also effective and may be useful for people who cannot take psychostimulants because of contraindications or adverse reactions, or who do not respond to them. However, the PBS listing of atomoxetine does not include treatment for psychostimulant non-responders. Atomoxetine is a noradrenaline reuptake inhibitor that was first approved in 2002 in the USA for treating ADHD. Although it has a similar preclinical pharmacology to the antidepressant reboxetine (Edronax), there is little evidence it has efficacy as an antidepressant. Atomoxetine reduced the symptoms of ADHD in several short-term placebo-controlled trials in children and adolescents (age 6-18 years) and adults. These results suggest that a clinician can expect to treat 4-5 children or adolescents to see one additional response to that seen with placebo. Continuous atomoxetine also reduced the chance of relapse in trials of up to 9 months. Methylphenidate and dexamphetamine are first-line drug treatments for ADHD, as their efficacy and safety are well established, based on clinical trials and extensive use (see the NPS RADAR article on methylphenidate extended-release for more information on psychostimulant prescribing). Without more evidence it is not possible to confirm that atomoxetine is either as effective or well tolerated as psychostimulants. The PBS listing for atomoxetine covers reimbursement for people with ADHD who cannot take psychostimulants because of a contraindication or adverse reaction. Atomoxetine is also a reasonable second-line choice for non-responders to psychostimulants, but the PBS listing does not cover this situation. Psychostimulant non-responders may have problems in addition to ADHD, or their primary diagnosis of ADHD may need to be reconsidered before trying second-line drug therapy.5 Differential diagnoses include anxiety, depression, and learning difficulties.

Atomoxetine may be less effective than psychostimulants

Few head-to-head trials have been published comparing atomoxetine with methylphenidate or dexamphetamine, and the available data have not established that atomoxetine is similar in efficacy to psychostimulants for ADHD. One unpublished trial found that after 6 weeks of treatment 56% of participants responded to methylphenidate while 45% responded to atomoxetine, a response-rate difference of 12% (95% CI 2% to 21%).21 A smaller, open-label study found no significant difference in response rates between the two ...